Operative Eingriffe an Hand und Handgelenk

Zusammenfassung: Trotz der heute zur Verfügung stehenden Biologika bleiben das synovialitisch bedingte Karpaltunnelkompressionssyndrom, das Caput-ulnae-Syndrom oder palmar betonte Tenosynovialitiden mit drohenden Sehnenrupturen dringliche chirurgische Indikationen an der Hand. Die diagnostische und therapeutische Synovektomie zur Diagnose- und Therapieoptimierung behält ihren Stellenwert, nach Möglichkeit bevor radiologisch fassbare Destruktionen auftreten. Balance- oder gelenkstabilisierende Operationen müssen vor der Destruktion der Gelenke angeboten werden. Wird dieser Zeitpunkt verpasst, so können am Handgelenk meist nur noch Teil- oder komplette Arthrodesen, an den Grundgelenken Arthroplastiken und an den Endgelenken Arthrodesen durchgeführt werde

Sonographic Wrist Measurements and Detection of Anatomical Features in Carpal Tunnel Syndrome

INTRODUCTION: This study compares anatomical findings at wrist level in patients with known carpal tunnel syndrome (CTS) and controls by ultrasonography (US). MATERIAL AND METHODS: Wrist-US investigations of 28 consecutive patients with 38 diagnosed, idiopathic CTS were compared to 49 healthy volunteers without history of CTS. Internal wrists dimensions, the presence of flexor muscle bellies in the carpal tunnel, and cross-sectional area of the median nerve were analyzed. The findings were correlated to gender, age, and BMI. RESULTS: US demonstrated a square internal carpal tunnel configuration in CTS patients compared to controls (P < 0.001). Patients with CTS showed a trend towards the presence of flexor muscles bellies in the carpal tunnel (odds ratio 1.77, 95% CI 0.337-8.33). CTS was present in women with higher BMI (P = 0.015). CONCLUSION: US allowed detection of specific anatomical features at wrist level in CTS patients. This observation may enable--following confirmation in larger prospective studies--risk evaluation for CTS development

A retrospective analysis of controlled active motion (CAM) versus modified Kleinert/Duran (modKD) rehabilitation protocol in flexor tendon repair (zones I and II) in a single center.

INTRODUCTION The aim of this study was to analyze primary flexor tendon repair results in zones I and II, comparing the rupture rate and clinical outcomes of the controlled active motion (CAM) protocol with the modified Kleinert/Duran (mKD) protocol. MATERIALS AND METHODS Patients who underwent surgery with traumatic flexor tendon lacerations in zones I and II were divided in three groups according to the type of rehabilitation protocol and period of management: group 1 included patients who underwent CAM rehabilitation protocol with six-strand Lim and Tsai suture after May 2014. Group 2 and 3 included patients treated by six-strand Lim Tsai suture followed by a modified Kleinert/Duran (modK/D) protocol with additional place and hold exercises between 2003 and 2005 (group 2) and between 2011 and 2013 (group 3). RESULTS Rupture rate was 4.7% at 12 weeks in group 1 (3/63 flexor tendon repairs) compared to 2% (1/51 flexor tendon repairs) in group 2 and 8% in group 3 (7/86 flexor tendon repairs). The grip strength at 12 weeks was significantly better in group 2 compared to the group 1 (35 kg/25 kg, p = 0.006). The TAM in group 1 [113° (30-175°)] was significantly worse (p < 0.001) than the TAM in group 2 [141° (90-195°)] but with similar extension deficits in both groups. The assessment of range of motion by the original Strickland classification system resulted in 20% excellent and 15% good outcomes in the CAM group 1 compared with 42% and 36% in the modK/D group 2. Subanalysis demonstrated improvement of good/excellent results according to Strickland from 45% at 3 months to 63.6% after 6-month follow-up in the CAM group. CONCLUSION The gut feeling that lead to change in our rehabilitation protocol could be explained by the heterogenous bias. A precise outcome analysis of group 1 could underline that in patients with complex hand trauma, nerve reconstruction, oedema or early extension deficit, an even more intensive and individual rehabilitation has to be performed to achieve better TAM at 6 or 12 weeks. Our study explicitly demonstrated a significant better outcome in the modK/D group compared to CAM group. This monocenter study is limited by its retrospective nature and the low number of patients

Perfusion-decellularization of human ear grafts enables ECM-based scaffolds for auricular vascularized composite tissue engineering

Introduction: Human ear reconstruction is recognized as the emblematic enterprise in tissue engineering. Up to now, it has failed to reach human applications requiring appropriate tissue complexity along with an accessible vascular tree. We hereby propose a new method to process human auricles in order to provide a poorly immunogenic, complex and vascularized ear graft scaffold. Methods: 12 human ears with their vascular pedicles were procured. Perfusion-decellularization was applied using a SDS/polar solvent protocol. Cell and antigen removal was examined by histology and DNA was quantified. Preservation of the extracellular matrix (ECM) was assessed by conventional and 3D-histology, proteins and cytokines quantifications. Biocompatibility was assessed by implantation in rats for up to 60 days. Adipose-derived stem cells seeding was conducted on scaffold samples and with human aortic endothelial cells whole graft seeding in a perfusion-bioreactor. Results: Histology confirmed cell and antigen clearance. DNA reduction was 97.3%. ECM structure and composition were preserved. Implanted scaffolds were tolerated in vivo, with acceptable inflammation, remodeling, and anti-donor antibody formation. Seeding experiments demonstrated cell engraftment and viability. Conclusions: Vascularized and complex auricular scaffolds can be obtained from human source to provide a platform for further functional auricular tissue engineered constructs, hence providing an ideal road to the vascularized composite tissue engineering approach

Hand and Wrist Surgery

Despite improved medical treatment of rheumatoid arthritis, carpal tunnel compression, caput ulnae syndrome and palmar and dorsal tenosynovitis with potential tendon rupture represent urgent surgical indications. While diagnostic and therapeutic synovectomy may guide medical treatment, it should be performed before joint instability and destructive arthritis are established. Swan-neck and Boutonniere deformities as well as ulnar or radial drift of metacarpophalangeal (MCP) joints or the wrist can only be corrected when the involved joints are supple and intact. In the presence of destructive arthritis, partial and total wrist fusion, arthroplasties of the MCP joints and arthrodeses of the distal interphalangeal joints are recommended